Reimbursement for your patient face-to-face professional services (Evaluation & Management) have traditionally been driven by volume and by level of service. With the shift to value-based reimbursement, the level of service must additionally be supported by diagnoses to realize optimal reimbursement. Claim submission is all about the data…using numbers (CPT codes, ICD-9/ICD-10 codes), to “paint” a picture of what is wrong with the patient, describe the services performed, and to request payment for that work. Volume to value doesn’t have to mean a reduction in revenue if you paint that picture accurately. What is your painting style? Jackson Pollock or Da Vinci?

For most specialties, professional services continue to make up a significant percentage of their practice revenue. For years the focus has been on volume in both the office and facility settings. We’ve optimized our schedules, trying to fit in 2-3 more patients every day. We’ve added Nurse Practitioners and Physician Assistants to our staff to increase our efficiencies, focus resources and see more patients. All while trying to adhere to the complicated coding and documentation guidelines. The ultimate goal: To bill the correct level of service based on medical necessity rules, reduce compliance risk with accurate documentation, and yet not undervalue our services.

Evaluating and understanding your practice CPT metrics is a key indicator in determining the revenue cycle performance across your enterprise. By using claims data, insurance payors (government and private payors alike) are tracking your metrics by system, by practice, by provider, and are comparing you to your peers. How well are you doing? As a first step, it is important to understand if there is utilization variability between individual physicians within your practice or system, and why that may be. We often see that E&M utilization varies widely among providers in the same group, and may be an indicator of an unclear understanding of coding rules and potential risk. By measuring and then tracking volume data, by provider, you can illustrate this pattern of behavior. With this data, a benchmark comparison can be performed, measuring both potential revenue opportunities and risk associated with current billing patterns.

While level of service is important and does have a significant impact on our reimbursement, we have now moved into the realm where accurate Evaluation & Management (E&M) diagnosis reporting has become equally important. A reflection of the patient’s severity and acuity is documented via the ICD-10-CM codes we submit for claims payment, and must be supported by the documentation. Your ability to accomplish this accurately and with the level of granularity required, will be reflected in risk scores and ultimately your reimbursement.

In this new and growing world of value-based medicine, providers will be challenged to improve their accuracy of reporting patient diagnoses. ICD-10 requires a greater level of specificity. However, specific diagnosis reporting has never been a strong suit, particularly in the ambulatory setting, where providers have relied on old stand-bys…the unspecified codes. Not because a greater specificity was unknown, but because simpler documentation was easier, less time-consuming, and in the old volume-based world it really didn’t matter. Reimbursement was the same for an encounter reported with CHF, unspecified (ICD-9 code 428.0) or acute on chronic systolic heart failure (ICD-9 code 428.23).

In addition to more specific diagnosis documentation, ensuring we capture and report all other impacting conditions and co-morbidities is necessary to accurately reflect the severity & acuity of the patient.

The challenge to improve documentation is in many ways hampered due to the one tool that was supposed to make documentation easier…the Electronic Health Record (EHR). Most EHR systems have become enablers in a world where there are just too many “clicks” involved to get through the day. Anything that will save a click or two becomes the default. Copy and paste has become prevalent. But those defaults and copy/paste actions can lead to incorrect documentation and inaccurate billing. A 2013 report published by Daniel R. Levinson, Inspector General for the Office of Inspector General (OIG) states:

“Experts in health information technology caution that EHR technology can make it easier to commit fraud.11 Certain EHR documentation features, if poorly designed or used inappropriately, can result in poor data quality or fraud.”

The report goes on to describe two examples of EHR documentation practices that could be used to commit fraud.

“Copy-Pasting. Copy-pasting, also known as cloning, allows users to select information from one source and replicate it in another location.12 When doctors, nurses, or other clinicians copy-paste information but fail to update it or ensure accuracy, inaccurate information may enter the patient’s medical record and inappropriate charges may be billed to patients and third-party health care payers. Furthermore, inappropriate copy-pasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims.”

“Overdocumentation. Overdocumentation is the practice of inserting false or irrelevant documentation to create the appearance of support for billing higher level services. Some EHR technologies auto-populate fields when using templates built into the system. Other systems generate extensive documentation on the basis of a single click of a checkbox, which if not appropriately edited by the provider, may be inaccurate. Such features can produce information suggesting the practitioner preformed more comprehensive services than were actually rendered.13”

Occasionally incorrect diagnosis reporting is an EHR workflow issue. Understanding how your particular electronic system assigns the primary diagnosis is critical. Many systems will reorder the diagnoses on claims in either alphabetical or numerical order if the primary diagnosis is not properly designated. This can lead to a stable co-morbid condition such as hyperlipidemia being reported as the primary condition, even when an acutely ill patient is seen.

Many have predicted that the transition to ICD-10 would fix this by forcing improved documentation. But did it? It’s not enough to select a very specific diagnosis for billing purposes. Documentation rules mandate that the diagnoses billed must be substantiated in the record for that date of service. We all recognize that the process of billing a claim to an insurance company (Medicare and Medicaid included), is an “on-your-honor” system…much like filing your taxes. You file and if you are due a refund, you get paid. In the healthcare world, you submit an insurance claim and provided there are no glaring edits or rejections, you get paid. This happens regardless of whether the documentation in the record actually matches what was billed.

CMS has stated that, “Abuse describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse includes any practice that is not consistent with the goals of providing patients with services that are medically necessary, meet professionally recognized standards, and priced fairly.

Examples of Medicare abuse include:
• Billing for services that were not medically necessary;
• Charging excessively for services or supplies; and
• Misusing codes on a claim, such as upcoding or unbundling codes. Medicare abuse can also expose providers to criminal and civil liability.

Figure 1 shows examples along the spectrum of causes of improper payments.”

The risk for incorrect coding and improper billing is in post-payment or retrospective audits, such as those performed by the CERT, RAC, and ZPIC programs. In a post-payment review, where supporting documentation is requested, providers are subject to repayment and/or possible penalties if the documentation does not support the codes billed. If a pattern of behavior is identified, you can expect additional scrutiny which could lead to pre-payment reviews, additional fines and penalties, or worse. In the past, these reviews have been primarily focused on documentation being supportive of the level of service, and much less so on the diagnosis. (Remember, we are talking about E&M services, not diagnostic or therapeutic procedures, which have been subject to coverage determination policies and diagnosis reviews for some time.)

Cost vs. Quality: Under the Quality Payment Program (QPP) and with penalties already impacting many practices in 2018, (based on 2016 data), what we are doing today, will impact our practices significantly in 2020. Think about a patient under the Merit-based Incentive Payment System (MIPS) who is attributed to you or your practice. A high-risk patient with expensive hospital procedures, interventions, and maybe even critical care services; and yet your claims have been inaccurately reporting low complexity or unspecified diagnosis codes. This misrepresents the true level of severity and acuity for that patient. Costs associated with that patient’s care will be high, and based on your diagnosis reporting, unexplained. Our billing and documentation must accurately reflect the high risk, complicated patients and their conditions that warrant such expensive interventions.

Paint by Numbers: Where do you start? How do you use CPT and ICD-10 numbers to accurately paint the picture for each patient? Level of service is still important. Providers must understand coding & documentation rules. Bill correctly for the medically necessary level of service provided to the patient. Don’t leave any money on the table by coding too low. Conversely, don’t expose yourself to unnecessary risk by coding higher than your documentation supports.

Develop a Clinical Documentation Improvement (CDI) program at the ambulatory level. Educate providers on current coding and documentation rules regarding levels of service, along with a new focus on diagnosis coding and documentation. Accurate and specific documentation will support the added granularity of ICD-10 codes.

Whether you participate in the QPP via MIPS or an APM, use these payment programs to maximize your Medicare incentives. Document well, bill accurately to paint a clear and well-defined picture, not a sloppy confusing or contradicting one. If costs are high, documentation will support why. You will not be an outlier to your peers.

The key is accurate coding, accurate documentation, and accurate reimbursement. By “painting” your documentation like Da Vinci, you’ll be off to a great start!